Section title: Requests for Interpretation
RFI #
2348
835 Claim Payment Adjustments
Description

The 835 TR3 reads as: 
"Although the service payment information is optional, it is REQUIRED for all professional claims or anytime payment adjustments are related to specific line items from the original submitted claim. When used, the submitted service charge plus or minus the sum of all monetary adjustments must equal the amount paid for this service line."
Is the intent that report of service line payment adjustments be REQUIRED on professional electronic (837P) claims?

Response

The situational rule for the 835 2110 loop SVC Service Payment Information Segment reads “Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send.”
The SVC segment is required for all professional (including 837P) claim payments. Additionally, all adjustment information related to that service must be reported in the 2110 loop CAS Service Adjustment Segment for that service line. The situational rule for the 2110 CAS Service Adjustment Segment reads “Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send.”
The service line must be balanced – the submitted service billed amount (SVC02) minus all service adjustment amounts (CAS03, CAS06, CAS09, CAS12, CAS15, CAS18) must equal the service paid amount (SVC03). See Section 1.10.2.1.1”Service Line Balancing” for additional information on service line balancing.

DOCUMENT ID
005010X221